Re-credentialing Notice

TO: United Physicians Member

DATE: ASAP
FROM: Robin L. King, Credentialing & Data Control
SUBJECT: Re-credentialing
As our contracted payers have delegated credentialing to UNIPHY it is required that all members be re-credentialed every three
years. If you are not re-credentialed within the specified time period, your membership will be terminated. Please mail the completed
packet to the address below.
1. Complete the practice information below:

Physician Name (Please print): Specialty:

Date of Birth: SSN: Indiv. NPI#:

SC Med.Lic#: DEA #:

Practice Name: Address:

Office Contact: E-mail address:

Phone: Fax: Tax ID:

Group NPI #:

Medical/Professional school Year completed

Board Certified (Y/N) Exp. Date: Name of Board:

Medicaid #: Medicare #:

2. List the hospitals you have privileges listing Primary hospital first
Name of Hospital Privileges (Active, Courtesy, etc.)

 3. Before we can begin re-credentialing, we must receive current copies of the following:
a. DEA and State Narcotics Certificate (DHEC)
b. State license
c. Malpractice Insurance cover sheet  MUST BE CURRENT
 Please include these copies
(If JUA, please also include the Patient’s Compensation Fund cover sheet) when returning packet.
d. Release of Information form (signed and dated)
e. Questionnaire (signed and dated)
Again, UPI is delegated to re-credential UPI members for plans with which we are contracted. Failure to return
this re-credentialing packet by the requested date above will jeopardize your participation in these plans.

PLEASE MAIL COMPLETED APPLICATION TO: UNIPHY

1739 Maybank Hwy, Ste.T-125
Charleston, SC 29412-2103

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 United Physicians Re-credentialing Questionnaire
If you answer “Yes” to any of the questions below, you must explain fully on separate sheet and attach to questionnaire.

1. In the past 5 years have you had any ongoing physical or mental impairment or condition which would make you unable
with or without reasonable accommodations to perform essential functions of a practitioner in your area of practice or
unable to perform those essential functions without a direct threat to the health and safety of others? Yes ( ) No ( )

2. Are you now, or have you ever been considered to have an impairment due to either chemical
dependency or substance abuse which my adversely affect your ability to practice medicine or Yes ( ) No ( )
surgery?

3. Has your license to practice medicine in any jurisdiction, your narcotic registration, or your Yes ( ) No ( )
board certification ever been revoked, changed, modified, or suspended?

4. Have you ever been convicted of fraud or a felony? Yes ( ) No ( )

5. Has your medical staff privileges at any hospital or membership with any medical organization
been either:
____limited ____not renewed ____subject to probationary conditions
____revoked ____voluntarily relinquished ____suspended ____denied Yes ( ) No ( )
or have proceedings toward any of those ends been instituted or recommended by a standing
medical staff committee or governing board for other than timely completion of medical
records?

6. Have any judgments, settlements, or claims been made against you? Yes ( ) No ( )

7. Have you ever been directly or indirectly involved or named in a suit or claim (open, closed,
or dismissed) alleging medical negligence, malpractice, referring to the care rendered to any
patient or associated with anything that would constitute moral turpitude? Yes ( ) No ( )

8. Have you every been denied any application for licensing in any state or application for
privileging at any institution in any state? Yes ( ) No ( )

9. Have you ever had your privileges to treat and reimburse through Medicare, Medicaid,
or any state agency limited, suspended, modified, or revoked? Yes ( ) No ( )

10. Have you ever participated in a managed care plan in which you were terminated, or been
denied participation in a managed care organization for any reason other than need? Yes ( ) No ( )

11. Have you ever been the object of an administrative, civil, or criminal complaint or investigation
regarding sexual misconduct? Yes ( ) No ( )

 IF YOU ANSWERED “YES” TO ANY OF THE ABOVE QUESTIONS, YOU MUST ATTACH
A WRITTEN DETAILED EXPLANATION 
ATTESTATION
(PLEASE SIGN AND DATE BELOW)
The undersigned hereby certifies that the above information requested by United Physicians is truthful, correct and complete in all
respects, especially regarding licensure, education, certification, malpractice coverage and privileges.* The undersigned further
understands that the intentional submission of false or misleading information or the withholding of relevant information is grounds
for termination as a participating physician with United Physicians.

Date: Name (Please Print):

Applicant Signature:

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 UNITED PHYSICIANS INC.
RELEASE OF INFORMATION

(Please read carefully before signing.)

This document serves as an authorization for a release of information from hospitals, health care institutions, facilities or
organizations, with which I have been associated, including but not limited to past and present malpractice carriers who may have
information bearing on my professional competence, character and ethical qualifications. I consent to have the credentialing offices of
these facilities provide the information necessary to complete this application. This information includes, but is not limited to,
education and training background, malpractice coverage, references, practice history, National Practitioner Data Bank, and other
information deemed relevant and necessary by United Physicians Inc. (UP). This information will be used solely for the purpose of
processing my application for membership or reappointment in UP. I understand that information supplied to UP will remain
confidential.

By applying for membership or reappointment in UP, I hereby signify my willingness to appear for interviews in regard to my
application. I hereby authorize UP, its members, agents, and its representatives to consult with administrators and members of the
medical staffs of hospitals or members of other related institutions with which I have been associated and with others, including past
and present malpractice carriers, who may have information bearing on my professional competence, character and ethical
qualifications. I hereby further consent to the inspection by UP, its members, agents, and its representatives of all records and
documents, including medical records held by hospitals, facilities, organizations or others, that may be material to an evaluation of
my professional qualifications and competence to carry out the clinical privileges requested as well as my moral and ethical
qualifications for membership.

I hereby authorize UP and/or their contracted HMOs and insurance groups and/or their affiliates, including other Third Party Payer
Peer Review Committee or health care providers’ Peer Review Committees to consult with, and obtain from, any and all individuals
and organizations who can provide information concerning my professional liability coverage and claims, information bearing on my
professional competence, character, health status, ethical and other qualifications and ability to work cooperatively with others I
hereby release from liability those individuals and organizations who have provided this information and UP, and/or their contracted
HMOs and insurance groups and/or their affiliates in using this information.

I understand and agree that I, as an applicant for membership or reappointment, have the burden of producing adequate information
for proper evaluation of my professional competence, character, ethics, and other qualifications, and for resolving any doubts about
such qualifications.

I particularly agree to subject my clinical performance to and faithfully participate in UP’s care management programs and other
quality of care and utilization programs as the same shall from time to time be in effect, and I agree to hold members of the
corporation and other authorized representatives of UP engaged in these quality of care programs free of all liability for their actions
performed in good faith in connection therewith.

I also understand and agree that a final determination to reject my application for membership or reappointment in UP, or, upon being
granted membership or reappointment, a final determination to terminate my membership, pursuant to UP’s Bylaws, Rules and
Regulations or Participating Physician Agreement, is a final determination and I hereby agree that I am not afforded any procedural or
substantive hearing or appeal rights by applying for or being granted membership in UP.

All information submitted by me in this application is true to the best of my knowledge and belief. I fully understand that any
misstatement in, misrepresentation, or omission from this application constitutes cause for the denial of membership or cause for
immediate dismissal from United Physicians Inc.

I also acknowledge the right to request and receive the status of my application, review information in support of my application and
the right to correct erroneous information should I be contacted about substantially different information received by United
Physicians Network.

Signature Date Print Name